Dissociation and the insanity defense: A review of U.S. Federal appellate case law.

Pathological dissociation is relatively common in the United States and may be associated with violent or criminal behavior. Dissociative Disorders, especially Dissociative Identity Disorder, are considered controversial diagnoses by some in the psychiatric and legal professions. Individuals who offend during dissociative states may not be criminally responsible if they meet the legal standard for insanity, however, insanity pleas based on dissociative symptoms are rare. This review examined Federal appellate case law for potential legal barriers to the insanity defense for dissociative conditions and any restrictions imposed on related expert evidence. Few rulings directly addressed these questions but there do not appear to be any unique barriers for dissociation-related insanity pleas. Some cases provided valuable insights regarding the admission of expert evidence, effective expert testimony, and the role of defense counsel.

Characteristics associated with criminal responsibility assessment outcomes among women in Central Canada.

The number of women involved with forensic mental health systems internationally is rising, however, limited research has explored the characteristics of those assessed for criminal responsibility. We investigated the demographic, psychiatric, and criminological characteristics of women recommended as eligible or ineligible for the defence of Not Criminally Responsible (NCR) on account of mental disorder following a criminal responsibility assessment in Central Canada. Data were collected through retrospective chart reviews of court-ordered criminal responsibility assessments for 109 women referred for evaluations between 2003 and 2019. Accused were an average age of 34.55 years, predominately identified as Indigenous (37.7%) or Caucasian (20.8%), and had often been charged with assault (47.7%). Women identified in the reports as NCR-eligible were significantly more likely to be employed, experience delusions during the index offence, and have expert reports linking their mental health symptoms to NCR legal criteria. They were also significantly less likely to have a personality disorder, substance-related diagnosis, or have used substances during the index offence. Delusions during the index offence significantly predicted assessment recommendations when controlling for age at assessment order, current substance-related diagnosis, and whether the expert report linked mental health symptoms to NCR legal criteria. Findings indicate the key factors considered by forensic mental health professionals when conducting criminal responsibility assessments with women. Meaningful differences exist between women identified as NCR-eligible and ineligible, with findings illustrating who may be more likely to receive services within the Canadian forensic mental health system.

Sleep disorders and criminal behavior.

Behaviors that would otherwise be considered criminal acts, but occur in the context of a sleep disorder, pose challenges to the traditional application of legal principles of criminal responsibility. Determining the degree to which consciousness is present during such behaviors becomes a necessary step in assigning criminal culpability. Historically, legal defense theories of unconsciousness, automatism, and insanity have been raised to negate culpability for parasomnia related behaviors. Accordingly, proper assessment of sleep disorders in the context of criminal charges becomes critical in assisting the functions of the justice system. This article reviews principles related to the legal tradition, expert assessment, and elements of expert testimony related to criminal behaviors and sleep disorders.

Mental health criminal defenses in persons with neuropsychiatric disorders.

Persons with neuropsychiatric disorders present specific and unique challenges for forensic experts and defense attorneys in the criminal justice system. This article reviews two potential criminal defenses: legal insanity and the various legal standards or tests of criminal responsibility that are used in jurisdictions throughout the United States (i.e., the M'Naghten standard and the American Law Institute's Model Penal Code), and the partial legal defense of diminished capacity (lacking the mental state necessary to be found guilty of a specific intent crime). The process of evaluating criminal responsibility or diminished capacity is also presented with a specific emphasis on common issues that arise in evaluating defendants with Intellectual Developmental Disorder (Intellectual Disability), Parasomnias, Seizure Disorders, and Neurocognitive Disorders.

Forensic neuropsychiatric aspects of epilepsy.

Epilepsy may be associated with automatisms that are classed as 'insane 'as they are deemed to have originated within the mind. 'Sane automatism' is said to occur from external factors, such as physical trauma, while 'insane automatism' is said to be innate to the individual experiencing them. To claim automatism within the context of a criminal matter requires a detailed evaluation of the behavior demonstrated and a questioning of the volitional and purposeful nature of this behavior. It is insufficient to rely upon past behavior in association with these seizures to justify the defense of automatism within a specific event. Epilepsy is often considered to be associated with an increase in violence. Proper epidemiological research, both in long-term, large population control studies and hospital-based studies, has suggested that epilepsy, per se, is not associated with an increase in violence when compared to the population at large and controlled for other familial and environmental factors.

The Value of Conditional Release for Insanity Acquittees.

The procedures and outcomes of conditional release of insanity acquittees is a relatively neglected area of forensic psychiatric research. The release procedures vary in individual states, resulting in a wide range of approaches, from the careful selection of appropriate patients and strict monitoring in the community, to literally no mechanism for ensuring the future safety of such individuals. In North Carolina there are institutional barriers which even hinder research on the outcomes of such cases. Haroon and colleagues report on the post-release outcomes of insanity acquittees in North Carolina from 1996 to 2020. The findings of the researchers are analyzed in light of the lack of a formal post-release monitoring system in their state, contrasted with outcomes in states where a strict monitoring program is in place. Commentary is provided on the study findings, including associations between demographic, psychiatric, and criminological characteristics of insanity acquittees and release outcomes, as well as an apparent systemic bias against minority acquittees in the insanity commitment and release process in North Carolina. Further research on this important topic, from additional state jurisdictions, is recommended.

An International Comparison and Review of Self-Induced Intoxication Causing Automatism.

The topic of self-induced intoxication causing automatism is a complex legal question that straddles the border of psychiatry, the law, and social policy. It has been argued that women and children are predominantly positioned as victims of sexual and domestic violence, in which substances often play a part. This consideration sensitizes society to any legal measures that may potentially excuse, mitigate, or absolve perpetrators. The legal systems in Canada, the United States, and the United Kingdom have dealt with these situations as best as they can, sometimes inconsistently and sometimes coming into conflict with the public discourse and subsequent legislation. This article presents a comparison of case law and legislation among these three countries. We review the concept of automatism and self-induced intoxication leading to automatism, and we show how the courts have dealt with this subject.

Are symptoms assessed differently for schizophrenia and other psychoses in legal insanity evaluations of violent crimes?

BACKGROUND: Forensic evaluations of legal insanity include the experts' assessment of symptoms present at the mental state examination (MSE) and the mental state at the time of offense (MSO). Delusions and hallucinations are most important. We explored how often symptoms were recorded in written forensic reports. DESIGN: This exploratory, cross-sectional study included 500 reports of legal insanity written in 2009-2018 from cases of violent crimes in Norway. The first author read all reports and coded symptoms recorded from the experts' assessments of the offenders. Two co-authors repeated this procedure for 50 randomly selected reports. Interrater reliability was calculated with Gwet's AC1. Generalized Linear Mixed Models with Wald tests for fixed effects and Risk Ratios as effect sizes were used for the statistical analyses. RESULTS: Legal insanity was the main conclusion in 23.6% of the reports; 71.2% of these were diagnosed with schizophrenia while 22.9% had other psychotic disorders. Experts recorded few symptoms from MSO, but more from MSE, although MSO is important for insanity. We found a significant association between delusions and hallucinations recorded present in the MSO and legal insanity for defendants with other psychotic disorders, but no association for defendants with schizophrenia. The differences in symptom recordings between diagnoses were significant. CONCLUSION: Few symptoms were recorded from the MSO. We found no association between presence of delusions or hallucinations and legal insanity for defendants with schizophrenia. This may indicate that a schizophrenia diagnosis is more important to the forensic conclusion than the symptoms recorded in the MSO.

Assessing Two Decades of Insanity Acquittee Release from the North Carolina Forensic Program.

Over the past two decades, an increasing proportion of North Carolina state psychiatric hospital beds have been used to house forensic patients. Insanity acquittees occupy almost all forensic-designated beds in the state. Despite the effect insanity acquittees have on state hospital use in North Carolina, outcomes for acquittees after they are released from the state hospital are unknown because of a lack of previous research. This study evaluates postrelease outcomes for insanity acquittees discharged from the North Carolina Forensic Treatment Program between 1996 and 2020. The study also describes the association between the demographic, psychiatric, and criminological characteristics of insanity acquittees and outcomes of recidivism or rehospitalization. The results show that insanity acquittees in North Carolina have higher rates of criminal recidivism than acquittees in other states. There is also evidence of systemic bias against minority race acquittees in the insanity commitment and release process in North Carolina. Outcomes for insanity acquittees released from the state Forensic Treatment Program could be improved through the introduction of evidence-based practices widely used in other states.

Forensic assessment instruments: Their reliability and applicability to criminal forensic issues.

Forensic evaluations have advanced considerably with the development of specialized measures validated on forensic and correctional samples. Prior to this progress, such evaluations relied heavily on extrapolations from general psychological tests to crucial, legally relevant questions. Since then, decades of empirical work have produced forensic assessment instruments (FAIs) addressing psycholegal standards in addition to forensically relevant instruments (FRIs) examining issues central to forensic practice (e.g., malingering) but not the standards themselves. This article provides a critical examination of the development, validation, and modern applications of six published FAIs that each address one of three broad criminal forensic issues (i.e., insanity, competency to stand trial, and Miranda abilities and waivers). Evaluations of the measures' reliability and validity particularly in forensic samples are highlighted. To complement FAIs, FRIs related to response styles are briefly explored. As a primary goal, forensic practitioners are provided with the knowledge and background about FAIs to enhance their criminal forensic practices.

Structured instruments for insanity defense evaluations: Opportunities and limitations.

Insanity evaluations are often criticized for their-alleged-lack of objectivity, reliability and transparency. Structured tools to guide and support forensic evaluators during these evaluations have been developed-but they are rarely employed in forensic practice. In the present article, we consider the value of these tools for forensic practice in terms of opportunities and limitations. First, we briefly describe different insanity criteria used in Western countries. Next, we will review five structured instruments to guide insanity assessment together with their performance measures. Finally, we draw conclusions on the value of such instruments for forensic practice.

Criminal insanity in Bulgaria and Norway: Analysing the prospect of a common approach.

This article raises the question of the prospect of a common approach to mentally ill offenders in Europe, through a comparative discussion of the criminal insanity rules and systems in Norway and Bulgaria. The underlying motivation is to fill a gap in current legal research where the insanity discourse is still to a certain extent nationally oriented. Bulgaria is to date not represented at all in the international discussion of criminal insanity. Starting out from recognizing the different history, rules, culture and welfare of Norway and Bulgaria, the authors argue that these countries have a similar practical understanding of insanity and how it is associated with mental disorders as well as common challenges in their forensic and legal systems. These insights can provide a basis for further comparative explorations concerning a possible harmonization of insanity law in Europe.

Ongwen and Mental Health Defenses at the International Criminal Court.

The International Criminal Court (ICC) case against Lord's Resistance Army commander and former child soldier Dominic Ongwen of Uganda resulted in a guilty verdict and 25-year prison sentence. Mr. Ongwen unsuccessfully raised defenses based on mental health. These included fitness to stand trial, insanity under Article 31(1)(a) of the Rome Statute (a first at the ICC), mitigation in sentencing based on diminished mental capacity, duress (also a first), and the cumulative effects of mental health and duress. These defenses were hampered by limited and ambiguous textual support, which occurs in a politico-legal context that is cautious regarding such defenses. Another group of challenges comes from the inherent difficulty of international forensic practice. In regard to how mental health affects the duress defense, the text of the Rome Statute and the Ongwen decision create a burdensome legal framework for defendants, particularly where mental illness limits but does not "destroy" decision-making, as Article 31(1)(a) requires for an insanity acquittal. Going forward, defense teams may attempt to address the court's all-or-nothing conception of mental illness, perhaps arguing a diminished mental capacity theory that accounts for psychiatric function that is reduced but not destroyed.

What Makes Forensic Psychiatric Experts Change Their Opinion in Supplemental Evaluations?

There are cases in forensic psychiatric evaluations with inconclusive information or with important information missing. In such situations, when new information becomes available the judge may ask an expert to supplement his/her report in the light of new information. For the purpose of this study, we collected 42 supplemental evaluations written in the University Psychiatric Hospital Vrapce to determine possible factors which were associated with changes in supplemental evaluations. The following data were gathered: demographic data, types of criminal offenses, reasons for the supplement evaluation, court questions, and diagnoses. Changes in supplemental evaluations occured more often when the defendants were diagnosed with a personality disorder (PD) only, compared to those who had a PD with a comorbidity, especially substance use disorders. Defendants with the diagnosis of a substance use disorder were 63.7% less likely to have changed experts' evaluations. The evaluations remained the same when the reason for supplemental evaluations were new witnesses' testimonies. Considering the principle of economy of actions in a judiciary system, a more critical approach should be taken when the judge requests a supplemental report.

Reshaping Insanity in Pakistani Law: The Case of Safia Bano.

This Article analyzes the 2021 judgment of the Supreme Court of Pakistan in the case of Mst. Safia Bano v. Home Department, Government of Punjab. The case has garnered significant local and international attention due to the Court's ruling that a death sentence may not be carried out on a defendant who has a mental illness. Setting the case against the backdrop of Pakistan's Islamic and colonial contexts, this article argues that the Supreme Court has reshaped the insanity defense in Pakistani law by placing the determination of a defendant's mental state mainly in the hands of medical professionals. However, the Court's reliance on medical professionals and the subsequent downplaying of the "moral capacity" element of the insanity defense-a determination of law made by courts-has created an obstacle for courts to punish offenders more stringently in future cases due to the popular belief that mental health professionals are ill-equipped to answer broader questions of justice for victims and society. The article recommends that this issue can be remedied by establishing an objective legal test for insanity that considers Islamic law, Pakistani precedent, and advances in medical science.

Making Sense of "Insanity": Law, Psychiatry, and the Royal Commission on the Law of Insanity as a Defence in Criminal Cases.

In 1954, the Canadian government established the Royal Commission on the Law of Insanity as a Defence in Criminal Cases. While its final report had little impact at the time, the creation of the commission points to the emergence of insanity as a newly complex problem within the context of postwar Canada. Spurred on by the growing psychiatric profession and the destabilization of capital punishment as a viable sentence, the commission quickly realized that the building blocks of its solution - legal and psychiatric expertise - were largely incompatible. This article explores the commission's problematization of insanity, which, far from providing solutions, highlighted the difficulties surrounding the integration of both psychiatric and legal knowledges of the day. The commission played an important role in upholding the status quo, and it provides an early example of the stasis that would characterize this area of the law until the early 1990s.

Résumé. En 1954, le gouvernement du Canada mettait sur pied la Commission royale chargée d'étudier la défense d'aliénation mentale en matière criminelle. Même si son rapport eut peu de répercussions à l'époque, la création de la Commission suggère que le problème de l'aliénation mentale avait acquis une complexité nouvelle dans le contexte de l'après-guerre au Canada. La Commission, aiguillonnée par la profession psychiatrique en expansion et la remise en cause de la peine capitale comme sentence acceptable, a vite réalisé que les éléments de base de la solution à ce problème ­ les expertises juridique et psychiatrique ­ étaient en grande partie incompatibles. Cet article s'intéresse à la manière dont la Commission problématise l'aliénation mentale : loin de fournir des solutions, elle fait plutôt ressortir la difficuté d'arrimer les savoirs psychiatriques et juridiques de l'époque. La Commission a joué un rôle important dans le maintien du statut quo, et constitue un exemple précoce de l'immobilisme qui allait caractériser ce domaine du droit jusqu'au début des années 1990.

Neurodevelopmental Conditions and the NGRI Defense.

Guina et al. summarize the literature on neurodevelopmental conditions and crime, focusing on the use of the insanity plea for this population. There have been a small number of cases in several jurisdictions, using both cognitive and volitional prongs, generating questions about the use of the defense for people with neurodevelopmental conditions. There are theoretical scenarios in which the defense seems appropriate, such as the argument that higher order moral reasoning is contingent on a series of developmental steps, including the development of theory of mind. Other lines of argument could be based on differences in conceptual thinking, reasoning, language, memory, attention, executive functioning, emotional regulation, and impulsivity. There are multiple barriers, however, to the use of the defense, including its antiquated language, which does not reflect our current conceptualizations of mental conditions and disorders. Another barrier is associated with the implicit stigmatization of defining a different way of being as a disorder, a position at the core of the important and burgeoning neurodiversity movement. It is not clear whether neurodevelopmental conditions will become the basis for an increasing number of insanity pleas, but more information in the form of primary data and good analysis is a critical next step.

The defense of mental disorder and crimes against the person committed under the influence of cannabis: A Canadian perspective.

The legalization of cannabis raises many queries, one of which regards the criminal liability of users under the influence of cannabis when crimes against the person are committed. This perspective review consequently aims to examine the defense of mental disorder (also referred to as the insanity defense) in Canadian criminal law and revise court decisions involving cases with cannabis use rendered in the field between 1995 and 2021. The purpose was to specify the factors allowing Canadian criminal courts to grant or refuse the defense of mental disorder to help further operationalize the jurisprudential criteria for forensic practice. We noted that presence of a severe and persistent primary psychopathology was the most decisive factor when determining the verdict of the accused who consumed cannabis.

Rational capacity and criminal responsibility in the USA.

The United States Supreme Court recently found that an insanity defense based upon moral incapacity was not constitutionally required. This decision allows states with a moral incapacity insanity defense, i.e., most states, to abolish their insanity defense. Unfortunately, the Court's opinion was based upon conflated concepts without considering irrationality, traditionally and universally the indispensable core element of insanity standards. This present perspective review attempts to clarify and disambiguate the critical concepts of instrumental and rational capacities as applied to insanity standards. With a proper understanding and application of these distinctly different capacities, insanity standards that at least incorporate rationality should in the future meet the Court's touchstone for determining constitutionally required due process.